Cultural Competency and Safety: A Guide for Health Care Administrators, Providers and Educators Compétence et sécurité culturelles : Guide à ...

 
Cultural Competency and Safety: A Guide for Health Care Administrators, Providers and Educators Compétence et sécurité culturelles : Guide à ...
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Cultural Competency and Safety: A Guide for Health Care
        Administrators, Providers and Educators

                                                          1
Table of Contents

Introduction ......................................................................................................................... 3
Background ......................................................................................................................... 3
International experiences .................................................................................................... 4
The need for cultural competency/safety in health care ..................................................... 6
Cultural safety in health care practice: Some examples ..................................................... 9
The need for cultural competency/safety in education ..................................................... 12
NAHO‘s views on culturally safe education .................................................................... 15
What should educators do to ensure a culturally safe environment for students? ............ 16
Cultural awareness in an educational setting: Some examples ......................................... 17
Conclusion: Cultural safety and competency in a First Nations, Inuit and Métis context 17
Appendix 1: NAHO‘s position statement on cultural competency and safety ................. 19
Appendix 2: General guidelines for health care ............................................................... 21
Furthers sources of information on cultural competency and safety .. ..............................25

Glossary ............................................................................................................................ 27
Works Cited ...................................................................................................................... 29
Endnotes............................................................................................................................ 31

                                                                                                                                      2
Introduction
The terms ―cultural safety‖ and ―cultural competency‖ have become part of common
parlance within the health care sector. But what do they mean? And why have they
permeated so many aspects of health care, health education and organizational health,
from local centres to national and international organizations across the globe?

These key terms have been used by, among others, the Maori working with New Zealand
health authorities to improve Maori health status and the National Aboriginal Health
Organization (NAHO) in Canada to improve the health status of First Nations, Inuit and
Métis.1

This document provides a background on the origins of cultural competency and cultural
safety, highlighting two international experiences as examples. The guide explains the
need for culturally competent and safe care, identifies the stakeholders in this process,
and outlines ways we can evaluate health care programs and policies to ensure that they
are culturally safe. We also look at culturally safe environments in education. Finally, we
examine how culturally safe environments in health care and education are applied to First
Nations, Inuit and Métis.

This living document is meant to be a general guide or resource for researchers, educators
and health professionals working in Aboriginal2 health. As a general guide, it does not
provide national or community-specific details, but rather shares an overview those
stakeholders should employ. Additionally, this document provides select resources,
contacts and links for further knowledge development.

Background
The term ―cultural safety‖ was developed in the 1980s in New Zealand in response to the
Maori people‘s discontent with nursing care. Maori nursing students and Maori national
organizations supported the theory of cultural safety, which upholds political ideas of
self-determination and decolonization of Maori people, and is based within a framework
of dual cultures.

In understanding cultural safety as a theoretical and methodological approach originating
with colonized Indigenous Peoples, we see the importance of its application across the
health care spectrum. Cultural safety moves beyond the concept of cultural sensitivity to
analyzing power imbalances, institutional discrimination, colonization and colonial
relationships as they apply to health care.

If we use a working definition of cultural competence as ―a set of congruent behaviors,
attitudes, and policies that come together in a system, agency, or among professionals and
enable that system, agency, or those professionals to work effectively in cross-cultural
situations‖ (U.S. Department of Health and Human Services, 2007, 10), we can begin to
see how changing the system through the use of an Indigenous understanding of cultural

                                                                                         3
safety can be possible. Cultural safety within an Indigenous context means that the
educator/practitioner/professional, whether Indigenous or not, can communicate
competently with a patient in that patient‘s social, political, linguistic, economic, and
spiritual realm. A culturally unsafe practice can be understood to mean ―any actions that
diminish, demean or disempower the cultural identity and well-being of an individual‖
(Nursing Council of New Zealand, 2002, 7).

Cultural safety requires that health care providers be respectful of nationality, culture,
age, sex, political and religious beliefs, and sexual orientation. This notion is in contrast
to transcultural or multicultural health care, which encourages providers to deliver service
irrespective of these aspects of a patient. Cultural safety involves recognizing the health
care provider as bringing his or her own culture and attitudes to the relationship.

International experiences
The following two examples of culturally competent and safe care were chosen for their
ability to address the Indigenous knowledge component of cultural safety and the
organizational processes to which changes would be made.

The Tikanga Best Practice Guidelines (2004), produced by the Waikato District Health
Board, New Zealand, are a set of guiding principles that directly tie culturally safe care
with Maori indigenous knowledge and practice. They are the basis of NAHO‘s guidelines
for cultural safety in health care centres.3 The Tikanga guidelines are organized around
the following themes:
        Whānau Rooms and general areas (rooms for family and extended family)
        Karakia (blessings/prayers/incantations)
        Taonga/valuables
        Information and support
        Whanau support (family)
        Food, toiletries and constitutions
        Body parts/tissues/substances (removal, retention or disposal)
        Organ tissue donation
        Pending and following death
        Tūpāpaku (care of the body)

The second international example providing key insight into the cultural competence
landscape is a document (2007) produced by the U.S. Department of Health and Human
Services‘ Health Services and Services Administration office. In it, the authors suggest
three areas of focus:

       Domains of cultural competence
       Focus areas within domains
       Indicators relating to focus areas, by type of indicator

                                                                                            4
For the Health Services and Services Administration Department of the United States,
who are addressing the discourse on cultural competence,

       [the] domains of cultural competence are the critical arenas or spheres in which
       cultural competence should be evident or manifest in an organization. These
       seven domains reflect to a great extent, although not exclusively, the underlying
       construct of cultural competence in health care delivery organizations and are
       areas to examine for evidence of cultural competence. (U.S. Department of Health
       and Human Services, 2007, ¶ 17.).

The seven domains (U.S. Department of Health and Human Services, 2007, ¶17.) are:
       Organizational values
       Governance
       Planning and monitoring/evaluation
       Communication
       Staff development
       Organizational infrastructure
       Services/ interventions

These two key examples have similar structural areas of focus and ways in which cultural
safety practice can be integrated into those structures.

                                                                                       5
The need for cultural competency/safety in health care
Rationale

There is growing recognition of the need for culturally safe care in improving the health
of First Nations, Inuit and Métis in Canada. The health status of Aboriginal Peoples is
below the national average (Shah, Svoboda & Goel, 1996). The experience of many
Aboriginal People with the mainstream health care system has been negative, often due to
cultural differences. Frequently, cultural differences and the inability of health providers
to appropriately address these differences have contributed to high rates of non-
compliance, reluctance to visit mainstream health facilities even when service is needed,
and feelings of fear, disrespect and alienation (NAHO, 2003, pp. 39-41).

Adopting a culturally safe approach to health care can benefit individuals, providers and
health care systems. When culturally appropriate care is provided, patients respond better
to care. Learning the skills needed to provide culturally safe care can benefit health
providers. It can lead to increased confidence on the job by having the ability to address
the needs of various groups in society. The resulting increase in job satisfaction may help
to increase retention rates in rural and remote communities.

Currently, the dominant discourse is on cultural awareness and cultural sensitivity. These
concepts largely focus on increasing health provider knowledge of various cultural
beliefs or trends (Papps, 2005). While NAHO supports cultural awareness as an
important part of cultural safety, it aims to emphasize that awareness is only the starting
point of the learning continuum. Cultural safety is near the end point of this continuum. It
is therefore important to note the distinctions between cultural awareness, cultural
competence and cultural safety. The provision of culturally safe care involves lifelong
learning and continuing competence. Cultural safety is the outcome of culturally
competent4 care.5

Misunderstandings can exist between health professionals and their clients and patients;
this can affect the ability of health professionals to help their clients and patients achieve
optimal health. For example, health professionals may view clients and patients who are
culturally different from themselves as unintelligent or of differing intelligence,
irresponsible, or disinterested in their health (Dowling, 2002, 4). This can result in poor
health status, marginalization within the health care system, increased risk, and
experiences of racism for the Aboriginal patient. The health care system may be
operating inefficiently, staff morale can be affected, health care costs may rise as patients
return with progressed illness, wait times may increase, health centres may be
overburdened, and the overall ethical standard of care is diminished (Fortier, 2004, 15).

How does change begin?

Changes to the ways health care education and practice is done must occur through three
main areas:
   1. Government

                                                                                             6
Federal, provincial and territorial levels
             Agencies and departments such as provincial and territorial ministries of
             health and education, Health Canada, and the Department of Indian and
             Northern Affairs
   2. Educational institutions, accreditation and regulatory bodies
             Educational institutions, accreditation and regulatory bodies
             Medical schools
             Universities and colleges with health programs
             Regulatory organizations: the Royal College of Physicians and Surgeons
             Canada (RCPSC), the Association of Faculties of Medicine of Canada
             (AFMC), the College of Family Physicians of Canada (CFPC)
   3. Stakeholder groups
             National Aboriginal Organizations: Assembly of First Nations (AFN),
             Inuit Tapiriit Kanatami (ITK), Congress of Aboriginal Peoples (CAP),
             Native Women‘s Association of Canada (NWAC), Métis National Council
             (MNC)
             National Aboriginal Health Organization (NAHO); Indigenous Physicians
             Association of Canada (IPAC); National Indian and Inuit Community
             Health Representatives Organization (NIICHRO); Aboriginal Nurses
             Association of Canada (A.N.A.C.)
             Community health centres
             Canadian Patient Safety Institute (CPSI)

If these three areas worked together, sharing guidance and wisdom through changes in
policy and planning, a new health system would emerge. This system could help improve
the health status of Aboriginal Peoples, decrease health care costs, and create greater
capacity for providers. Ideally, these groups could work toward the same, mutually
beneficial goals.

What to look for

According to the US Department of Health and Human Services, ―cultural competence
service delivery is both a quality and business imperative that should be incorporated at
every level of an organization‖ (U.S. Department of Health and Human Services, 2007,
¶9). But what roles should government, educational institutes and stakeholder groups
play? And how can they be engaged to ensure that appropriate standards are
implemented. Each stakeholder needs the ability to assess the level of cultural safety
within their community. Once they establish measures to gauge the level of cultural
safety in the management of the organization/institute, assessment recommendations can
lead to continuing cultural safety as a priority.

As stated in the executive summary of a U.S. Department of Health and Human Services
(2001) report on standards for culturally and linguistically appropriate services in health
care, ―experience from other fields demonstrates that health care organizations, providers,
policymakers, and accreditation organizations benefit when expectations are clear yet

                                                                                            7
flexible, resources for implementation are made available, and mechanisms for review
and oversight are specified‖ (p. xvi).

Does it work?

Once changes in practice and delivery occur, there are ways to measure whether or not
they have worked. According to Schyve (2002, ¶6), there are three signs of positive
cultural change. They can be found in:
        Leadership—there must be a proactive risk reduction program in the organization
        that enables leaders to pay attention to communications throughout the
        organization.
        Information—if something does go wrong, the patient must be informed that this
        result was not what was planned or anticipated.
        Education—the patient and his or her family must be informed about their
        treatment in a way that they can understand.

Other key areas of cultural safety to look at are:
       Patient satisfaction
       Comprehension
       Adherence to treatment recommendations
       Appropriate utilization
       Accurate diagnosis
       Appropriate treatment
       Organizational improvements
       Enhanced self efficiency
       Cost–benefit
       Improved clinical outcomes–disparity reduction
       Containing costs
       Improving clinical and organization quality
       Relationships between key stakeholders, patients and care givers (Fortier, 2002,
       6-8).

If positive changes occur in any of the key areas of cultural safety listed above through
practice and delivery, I.e., increased patient safety, we can say that cultural safety was a
factor in bringing about these changes. And the positive changes in practice and delivery
should be continually applied and evaluated.

Evaluation

Evaluation is necessary to gauge the level of effectiveness of changes brought about by
using cultural competency to create cultural safety. Indicators should reflect the type of or
level of patient satisfaction, the extent to which the patient feels they are a member of
their own health care team, and the degree organizational change? Schyve (2002) argues
that these three areas are important when looking at indicators of change.

                                                                                               8
Patient satisfaction: ―Patients and families are more satisfied with the care they
       receive when they feel they‘ve engaged in successful communication. More
       importantly, an atmosphere that fosters communication actually affects health
       outcomes. If the caregivers get the information they need from the patient, and if
       the patient understands what is being advised, the outcome improves… When
       patients fully participate in decision-making about their care, they increase their
       own safety (Schyve, 2002, ¶7).
       Member of health care team: ―The patient must be considered a critical member
       of the health care team. …[and] needs to know that he or she will not only be
       heard, but understood and valued. This is how trust is built (Schyve, 2002, ¶8).
       Organizational change: ―The organization does a self-assessment every 15 to 18
       months, midway through the accreditation cycle, which gives surveyors what they
       call a ‗priority focus‘‖ (Schyve, 2002, ¶11).

The U.S. Department of Health and Human Services developed the National Standards
for Culturally and Linguistically Appropriate Services in Health Care (2001), an
assessment tool for organizational competency/safety that tests an organization‘s ability
to:
        Develop an analytic framework for assessing cultural competence in health care
        delivery organizations.
        Identify specific indicators that can be used in connection with an evaluation
        framework.
        Assess the utility, feasibility and practical application of the framework and its
        indicators.
        Understand the relationship between culturally competent health services and
        patient satisfaction/clinical outcomes/health status.

An evaluation framework should be designed to reflect the priorities and definitions of
culturally safe care as set out by First Nations, Inuit and Métis. Evaluation should be an
ongoing process.

Cultural safety in health care practice: Some examples
How does a health care provider treat someone in a culturally safe way?
Here are some examples of how a health care worker can modify his or her behaviour in
order to better serve a client/patient.

Communication

       Discussion and explanations should be in plain language, recognizing that the
       language of care may not be the patient‘s first language. Care providers must
       learn to not use jargon, technical or academic terms, and explain things simply
       and clearly However, it is important that plain language should not be used in a
       way that makes the patient feel they are considered less intelligent..

                                                                                             9
Non-verbal behaviour varies among cultures and people. Some patients may feel
      uncomfortable maintaining eye contact, especially in stressful situations or with
      strangers. A health provider should not make assumptions about what non-verbal
      behaviour means, but should simply accept that the patient is behaving in a way
      that is comfortable or important to him or her. The caregiver should also try to
      adapt his or her own non-verbal behaviour to the patient‘s in appropriate ways.
      For example, a caregiver working with Inuit patients and their families should be
      aware that many Inuit use blinking as a confirmation of understanding.

      Patients are more likely to feel safe and empowered to tell caregivers about their
      needs and concerns if physicians encourage them to ask questions. Health
      providers who come across as more concerned with patients‘ questions than with
      time constraints are more likely to provide safe care.

Decision-making

      A health worker can show respect for the individual by offering the client/patient
      explanations and involving them in decisions about their care, rather than making
      demands on them or issuing unexplained directives. For example, having the
      client/patient go through the situation and advice with the health worker to see if
      it ―makes sense‖ to them and for them. People need information to be able to
      decide if they want and need to follow through, or if a course of action fits with
      their context, needs or abilities. For example, the health worker could say
      something like, ―There are a couple of things I can suggest that might work. You
      could try… This can be helpful because … How does that sound to you?‖

      If it is important that the patient do a specific thing, the health worker should give
      them a specific explanation, and so on. For example, if a patient must take
      medication several times a day for a period, rather than just saying, ―Take one pill
      every four hours for a week‖, a health worker should explain the reasoning behind
      it: ―It‘s really important that you take all of it according to the schedule. You‘ll
      probably start to feel better after a couple of days. However, even though you feel
      better, the germs are still in your body. It takes all this medication, spread out over
      a week, to kill all the germs. If any of them are left, they‘ll multiply and you‘ll get
      sick again.‖

      If a health worker presents a course of action, and the patient/client says she can‘t
      do that without first discussing it with her husband, the health worker needs to be
      respectful of that. The course of action may not require a spouse‘s approval, but
      the health worker must understand the patient‘s life context and values, in spite of
      their differences: ―Good, you discuss it with him. Can you come by again
      tomorrow and let me know? Then we can discuss the details.‖

                                                                                          10
Understanding and misunderstanding

          People do not want to look silly, and may feel uncomfortable questioning
          authority. For many reasons, they may say yes when in fact they mean no, or no
          when in fact the answer is yes. For example, when a health worker has explained
          medical requirements and procedures and asks, ―Any questions? Anything you
          don‗t understand?‖, the patient may say ―No,‖ even when they do not understand.
          Using clear and plain language can help avoid problems. It may be helpful to
          write down information and instructions so the person can think about it in
          private. But keep in mind the client‘s literacy level. Some further explanation may
          be helpful too, such as ―We doctors don‘t always explain things too well. I really
          would appreciate if you‘d get back to me if you have any questions. It will help
          both of us. I‘ll know what I missed, and you‘ll get the right information.‖

Beliefs

          Clients/patients may have beliefs about causes and cures that do not fit with
          established medical views. For example, if a client/patient explains that the full
          moon makes him/her act in strange ways (the role of the moon in mental
          illness/aberrant behaviour is still widely believed around the world), the health
          provider should simply accept the explanation and work with/around it: ―Yes, the
          moon is said to affect people. Let‘s look at what‘s happening in your situation.
          There may be ways we can reduce the effects.‖

Examples of cultural awareness

In the Canadian context, a health professional that is culturally aware would:

          Be aware that a client/patient of First Nations, Inuit or Métis heritage may have
          consulted a traditional healer, and be prepared to ask about this.
          Be aware of the level of directness in questioning that would be culturally
          appropriate for an Aboriginal person, while recognizing the diversity of First
          Nations, Inuit and Métis cultures.
          Be aware that some Aboriginal people tend to minimize a health problem, and
          accommodate accordingly for any understatements a patient might make in the
          assessment of their health.

It is important to note that these examples do not apply to all cultural groups.

Examples of culturally safe or unsafe practice

Culturally safe practice involves building health care providers‘ communication skills so
they:

          Are aware of what needs or issues their client/patient might have.

                                                                                              11
Are able to ask questions to get the information needed to best serve their
       client/patient.
       Pay close attention to and do not negatively judge verbal and non-verbal
       information that patients provide.

Here are some examples of some culturally safe and unsafe practice:

       Nurse practitioners at the Wabano Centre for Aboriginal Health in Ottawa offered
       this example of cultural safety. It is well known among health providers at this
       centre that many of their Métis and non-status First Nations patients do not have
       access to insured health benefits.6 Thus, when the nurses give out prescriptions,
       they know that patient may not be able to get them filled. Nurses take alternative
       actions to ensure that patients receive the care necessary to maintain good health
       or fight illness. For example, they may offer free drug samples to patients, or refer
       them to employment search services and food banks, or engage in other patient
       advocacy activities.

       An article (Browne, Fiske and Thomas et al, 2001) on First Nations women‘s
       encounters with mainstream health care gives the following example of a
       culturally unsafe experience: An Aboriginal woman comes into the hospital with
       a black eye and a wailing child. Health care workers immediately apprehend the
       child to child and welfare services without first checking the patient‘s medical or
       personal history. Culturally unsafe assumptions about abuse and the woman‘s
       ability to take care of her child underlie these actions (17).

       The prevalence of sexual abuse in communities means some Aboriginal women
       may be reluctant to seek out health care encounters involving bodily exposure in
       order to avoid feeling invalidated or shamed. As a result, they do not want to draw
       attention to their bodies or are afraid of having a doctor or nurse examine or touch
       their bodies, especially if they are male. A health care worker who communicates
       effectively with the patient to ensure comfort during the examination would be
       acting in a culturally safe way.

The need for cultural competency/safety in education
Rationale

The need for culturally safe care in improving the health of First Nations, Inuit and Métis
is matched by the need for culturally safe learning to improve educational outcomes for
Aboriginal students.

Aboriginal students‘ experiences with the mainstream education system are often
negative due to cultural differences in the learning environment. Unfortunately, this is
common because educators often lack the skills and knowledge needed to appropriately
address cultural differences in the curricula and classroom. These differences have

                                                                                         12
contributed to low retention and completion rates, poor performance, decreased peer
interaction, and poor attendance. Moreover, students may experience apprehension,
marginalization, racism, disrespect, and oppression within the learning environment.

Developing a culturally safe learning environment benefits students, educators,
educational institutions, and education systems. A student is more likely to respond
positively to the learning encounter when they feel safe, respected and able to voice their
perspective. An educator is more likely to experience more job satisfaction when
attendance is better, when the quality of scholarship is good, and when the classroom is
an environment of equal engagement between different ways of knowing. This comes
from an educator creating a culturally safe learning environment and delivering culturally
safe curriculum. High retention rates of an Aboriginal population can be interpreted as a
reflection of an educational institute‘s commitment to such an environment, as well as
their commitment to human rights and race relations. Such institutions produce more
graduates, which attracts more students and thereby increases enrollment.

A culturally safe learning environment would likely lead to an increased number of
Aboriginal health care providers. More Aboriginal people in the health care field could
improve health outcomes for First Nations, Inuit and Métis. Persons who develop current
competencies and create learning environments are recognizing this need and are
beginning to look at how the situation can be improved.

How does change begin?

Education in cultural safety at the post-secondary level is an important starting point for
increasing the number of health professionals that provide safe care. Introducing a
cultural safety approach early on will ensure students, knows how to provide the most
effective care to diverse populations when they enter the health care workforce.

What to look for

In supporting cultural safety education, the following approaches are recommended:

Recognizing the historical context

       Focus on teaching students about colonization and the economic, political,
       historical, and social causes of current health problems—rather than focusing on
       increasing knowledge about Aboriginal customs, health beliefs, etc.
       Educate students on the historical processes behind current plights will help them
       to avoid victim-blaming.7

Recognizing diversity of populations

       Make students aware of the diversity between Aboriginal Peoples—First Nations,
       Inuit and Métis—and the diversity within. There are 630 First Nations each with
       their own culture, language, etc., and urban, rural and remote populations.

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Providing culturally safe care may mean different things for each of these groups
       and even within the group.

Understanding health care worker–patient power relations

       Focus on understanding the power imbalances that can exist (in favour of the
       health care worker) between the health care worker and the patient. Students
       should learn how to exchange and negotiate power with the patient as they would
       within the teacher/student dynamic.

Raising organizational awareness

       Give staff orientations on cultural safety issues to everyone involved in the
       Aboriginal education program—deans, professors, teaching assistants, lecturers,
       administrative staff, and counsellors.

Does it work?

Care can be seen as becoming more culturally safe as change moves through a cultural
safety education continuum.

Cultural competency/safety education continuum

                   Culturally                           Culturally
                   Competent                            Competent
                    Educator                             Curricula

                                Culturally Safe Environment

                                         Student

                                    Culturally Competent
                                   Health Care Professional

                                Culturally Safe Care

Evaluation

Some of the indicators that can be used to measure the degree of engagement an
organization has with cultural competency and safety include:
       Increase in resources for Aboriginal health.8
       Increase in number of Aboriginal students.
       Increase in retention of Aboriginal students.

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Increase in integration with and availability of traditional forms of health and
       healing.
       Increase in Aboriginal-designed and Aboriginal-informed—culturally
       competent—health curricula.
       Increase in Aboriginal health educators.
       Increase in Aboriginal students‘ completion rates.
       Marked support of and participation in cultural competency/cultural safety
       workshops and professional development opportunities by non-Aboriginal health
       educators.

NAHO’s views on culturally safe education
To understand what culturally safe educational practices are, it helps to consider first
what is unsafe. NAHO identifies culturally unsafe practices in education as:

       Values, ethics and epistemologies (ways of knowing) for First Nations, Inuit and
       Métis that may be different from the mainstream are not recognized or valued.
       Indigenous knowledge is not acknowledged, or is treated as inferior to non-
       Indigenous knowledge.
       There are negative portrayals of First Nations, Inuit or Métis in curricula.
       Historical experiences and effects of colonization on First Nations, Inuit and
       Métis are not acknowledged.
       There are barriers to basic access to education.9

Conversely, culturally safe education occurs when all students take on the responsibility
to:
      Self-evaluate by understanding their roles and be willing to examine their own
      values, ethics and epistemologies (ways of knowing).
      Recognize that they may have conscious or unconscious conceptions of
      cultural/social differences in health care.
      Identify pre-existing attitudes and be willing to transform their attitudes by tracing
      them to their origins and seeing their effects on practice through reflection and
      action.

The educator then takes on the responsibilities to:

       Develop and teach curricula that reflects the Aboriginal experience and context.
       Engage in dismantling barriers.
       Recognize and show respect for Indigenous knowledge.

When both student and educator work from a place of cultural competency, cultural
safety becomes attainable.

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What should educators do to ensure a culturally safe
environment for students?
      Learn about the health and social challenges (and their social, economic,
      historical, and political determinants) faced by First Nations, Inuit and Métis.
      Expect that these issues may be of particular interest to Aboriginal students.
      Be able to understand Aboriginal health concepts.
      Understand the history of colonization and its impact on current health and social
      status of First Nations, Inuit and Métis.
      To be self-aware, evaluate the values, beliefs and assumptions they are bringing to
      the educator–student relationship.

How does an educator treat someone in a culturally safe way?

Communication

      Recognize when you are using a student‘s community as an example in problem-
      based learning (PBL) and that they may be able to offer alternative insights.
      Be open to traditional or Indigenous approaches to health when engaged in
      discussion.
      Recognize that some of the health or well-being issues discussed are potentially
      some students‘ realities (e.g., tuberculosis, over-crowded housing, etc).
      Establish the learning environment as a place of respect and open dialogue where
      students are equals.

Decision-making

      Whenever possible engage students in decision-making about the educational
      path, such as practicum location/scheduling and course selection.
      Provide the students with options on acceptable resources; the opportunity to use
      Indigenous texts, research, and other media.
      Encourage students to suggest guest speakers or set up site visitations.

Understanding and misunderstanding

      Avoid generalizations. Use specific examples, e.g., diabetes rates differ greatly
      among and between First Nations, Inuit and Métis.
      Do not burden an Aboriginal student by making them the First Nations, Inuit or
      Métis ―expert‖ in the class.
      Be able to adequately address the difference between Aboriginal rights and health
      issues to that of new Canadian populations.
      Establish a clear line of counsel and recourse should problems such as racism
      come up.
      Acknowledge that you as an educator are not an expert on all aspects of First
      Nations, Inuit or Métis individual and communities.

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Beliefs

          First Nations, Inuit and Métis often include spiritual health as an aspect of health
          and healing. As an educator you need to be open to and accepting of these topics
          in students‘ discussion, analysis or writing.
          Recognize and respect students‘ need to participate in ceremonies outside of the
          standard religious holidays, arranging for time off or when necessary.

Cultural awareness in an educational setting: Some examples
A health educator that is culturally aware would:

          Address the social determinants that may lead to a health issue such as obesity.
          For example, when addressing rates of obesity in Aboriginal communities, realize
          that northern communities have limited access to low-cost fresh foods and easy
          access to low-cost high fat foods.

          Include in the course positive examples that are relevant to First Nations, Inuit
          and Métis.

          Recognize appropriate terminology and use it, such as nation and/or community
          names.

Conclusion: Cultural safety and competency in a First Nations,
Inuit and Métis context
Cultural safety is rooted in the education of health care providers. If the health
professional or paraprofessional is able to create a culturally safe environment, then we
can assume that they have internalized the ability to be sympathetic, sensitive and
empathic, and are willing to incorporate the necessary measure to bridge the gap between
giver and receiver and learn that often the one who believes they are the giver is often the
receiver. This leads to bridging the gap between staff/organization and patient/student.

The crosscutting foundational principles of cultural safety discussed earlier are applicable
to First Nations, Inuit and Métis. However, it is imperative that the educator/practitioner
recognize the distinctiveness of First Nations people as similar yet different than Inuit,
and similar yet different then Métis, and so on. While they share a common history and
have been subject to similar constraints of colonialism, each population has within its
own population great diversity.

This is not to say that the tools provided in this text are not useful, but only to say the
educator/provider has a responsibility to learn, acknowledge and appreciate the
Indigenous knowledge of the group to which they are working with, when feasible. When
thinking about how to best meet the group‘s health priorities, the educator needs to take

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into account the different determinants of health each group faces, such as geography,
economy, community cohesion, access and capacity, and educational attainment.

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Appendix 1: NAHO’s position statement on cultural
competency and safety
NAHO‘s position statement on cultural competency and safety was first drafted in 2003
and received Board of Directors approval that same year, However, as it is a living
document, revisions have occurred to best address emerging knowledge of competency
and safety issues in First Nations, Inuit and Métis health care and education.

1. Cultural Safety

Cultural safety refers to what is felt or experienced by a patient when a health care
provider communicates with the patient in a respectful, inclusive way, empowers the
patient in decision-making and builds a health care relationship where the patient and
provider work together as a team to ensure maximum effectiveness of care. Culturally
safe encounters require that health care providers treat patients with the understanding
that not all individuals in a group act the same way or have the same beliefs.

2. Reform

The achievement of cultural safety in Aboriginal health care requires two-fold change. It
involves micro-level building of cultural competence in health care providers. In order
for this to happen, the achievement of cultural safety requires systemic change in health
education curriculum and the adoption of cultural safety standards of care by national
accreditation bodies at the macro-level. The achievement of cultural safety depends on
widespread support from clinicians, educators, researchers, and policy-makers.

3. Scope of Practice: Building the Cultural Competence of Health Care Providers

Cultural competence in health care providers can be achieved when providers build
external— and self—awareness and when they learn the specific skills necessary to
provide culturally safe care.

   3.1 Awareness

       Every health encounter involves the meeting of two distinct cultures—that of the
       health professional and that of the patient.
       Those receiving the service define culturally safe care. This can happen when
       trust is established between health care provider and patient.
       Focus on ―self-awareness.‖ Students during their residency should evaluate what
       they are bringing to the health encounter in terms of their own invisible baggage,
       that is, attitudes, metaphors, beliefs, assumptions, and values.
       The development of respect toward others is vital for the development of cultural
       safety (Dienemann, 1997). The need for respect is nurtured in education and
       required in practice when providers encounter differences in beliefs, rituals,
       speech, symbols, power, status, gender, ethnicity, or sexual orientation. While the

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health practitioner does not need to approve of differences that are present,
       respect is essential if cultural competency is to be demonstrated in practice.
       Cultural safety involves the recognition that health providers
       consciously/unconsciously exercise power over patients.
       Cultural safety involves a shift in attitude toward the recognition of patients as the
       ―experts‖ on themselves.
       Cultural safety involves gaining an understanding of the inadequacy of health
       services to many Aboriginal Peoples.
       Cultural safety involves gaining recognition of negative attitudes and stereotyping
       of individuals based on the ethnic group to which they belong.

   3.2 Practice

       Cultural safety involves building a health care relationship where the health care
       practitioner and patient work together as a team.
       Cultural safety involves learning how to communicate with a patient in a
       respectful, inclusive way, listening with the ears, the mind and the heart, engaging
       in good questioning, demonstrating understanding and acceptance, using everyday
       language to communicate with a patient, involving patient in care planning, and
       so on.
       Culturally safe care should be provided mindful of the individual diversity10 of
       patients.

4. Systemic Change

The responsibility for supporting culturally safe care is shared between individuals,
professional associations, regulatory bodies, health services delivery and accreditation
organizations, educational institutions, and governments. Accreditation bodies and
educational institutions can support culturally safe care by adopting standards of care that
encompass the principles of cultural safety.

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Appendix 2: General guidelines for health care
The following guidelines are adapted from New Zealand‘s Tikanga Best Practice
Guidelines (Waikato District Health Board, 2002) and are intended to give the reader
some basic tools for cultural safety within a health care setting. These are general
guidelines that will need to be adapted specifically to First Nations, Inuit or Métis.

For example, there is great diversity between First Nations, Inuit and Métis and within
each group. A Mi‘kmaq patient would have different ceremonial practices and protocols
than a Cree staff member. To be effective, these guidelines have to be built into the
organization at all levels. At orientation, new staff members are informed of the
guidelines, instructed on how to carry them out and told who the resource person is,
should they need further guidance.

Guidelines for Practicing Cultural Safety

1. Create Aboriginal Rooms: First Nations, Inuit, Métis

Some areas are permanently governed by First Nations, Inuit and Métis protocol. In these
areas protocols should be observed by all staff and other people using the facility.

Ensure that the areas designated are not marginalized with the institution. The patient and
family want to know they are part of their environment, not an afterthought.

   Staff action:
       Staff must respect these areas set aside permanently or on occasion. If you are not
       sure what appropriate First Nations, Inuit and Métis protocols are, please ask the
       staff in those areas or a First Nations, Inuit and Métis staff member of the same
       nation/community (if known).

2. Ceremony, Song and Prayer

For many Aboriginal Peoples, ceremony is essential in protecting and maintaining their
spiritual, mental, emotional, and physical health–particularly in a health care setting.

Staff action:
        Offer the Aboriginal person the choice of having ceremony at all stages of the
        care process and, where possible, including heightened situations (psychotic
        events).

Support this by:
      Allowing time for ceremony.
      Not interrupting a ceremony or ceremonies unless the physical care of the patient
      is compromised.
      If it is not possible for ceremony to occur, explaining why in a sensitive manner
      and discussing possible options.

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3. Sacred/Ceremonial Items

Various items are considered sacred to First Nations, Inuit and Métis and strict protocols
and ceremonies govern their usage.

Staff Action:
       Be aware and respectful of the items and discuss any need to handle them with the
       patient and/or their family members.
       Exercise particular care with gender-specific protocols for ceremonial items.
       Provide a list of various items that may fall within this category.
       Participate in education and training opportunities around sacred and ceremonial
       processes.

Support this by:
      Securely taping the item to the body of the patient rather than removing it, where
      possible.
      If risk is involved, obtaining the consent of the patient before removing the item.
      Giving the patient or family member the option of removing it themselves.
      Giving the family member or an Aboriginal staff member the option of caring for
      any items.
      Informing the patient and or family member any risk of storing the items and how
      they will be stored.

4. Information and Support

The aim is to provide health care in an environment that is culturally safe. This is done
out of respect for different cultural perspectives and needs, and also to support the total
health of the person receiving health care.

If necessary, translate the concept of cultural safety/competency into the predominant
Indigenous languages of the area. There may be no direct translation for the words, so
attention must be given to the context and what the concepts could mean in an indigenous
context.

Staff action:
        Ensure the patient and their family understand what is happening and what
        resources and support are available, including traditional healers, patient
        advocates and clergy.
        Ensure the patient and their family is given sufficient time to understand the
        information shared and have the ability to speak to the provider again.
        Create a friendly environment. For example, include Aboriginal art and design in
        the care facility. The patient and their family need to see themselves reflected in
        the environment.

Support this by:

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Clearly introducing yourself and your role/service.
       Ensuring that all information is given clearly and is understood by the patient
       and/or their family.
       Understanding that for First Nations, Inuit and Métis, the concept of ―next of kin‖
       may be broadly interpreted at registration.
       Notifying appropriate Aboriginal staff of the patient in the care as soon as
       possible (i.e., on admission/registration).
       Offering an interpreter where appropriate.
       Ensuring the patient and family are aware of the Aboriginal accommodation
       services, preferably prior to admission.
       Keeping an up-to-date list of resources that are available (patient advocate
       services, Aboriginal rooms and other dedicated spaces, external Aboriginal
       providers, and support services), and informing the patient and their family about
       these resources.

5. Family Support

Family and extended family is of fundamental importance to many Aboriginal Peoples.
The concept of family may extend beyond the nuclear or biological family concept.
Family support can be crucial to the patient‘s well-being.

Staff action:
            Encourage and support the Aboriginal patient and their family, include them
            in all aspects of care and decision-making, provide education needed for them
            to make those decisions.

Support this by:
           Sharing a copy of the care plan with the Aboriginal patient and family with
           the patients permission (you must comply with federal or provincial privacy
           legislation).
           Developing a copy of the care plan by an interdisciplinary team with the
           patient and family and/or designate.
           Asking the patient and/or family if they wish to nominate a person to speak on
           behalf of the family; they will have to acknowledge that this person will have
           access to their medical records.
           Acknowledging and involving the person nominated.
           Including appropriate Aboriginal staff in patient care. They may provide
           assistance with the decision-making process, if this agreed to by the patient
           and family.
           Where possible, finding private space and adequate time to consult with the
           family throughout the care process, and checking with the family about
           suitable meeting times and their needs.
           Being flexible about visiting times and visitor numbers where possible.
           Being supportive of family visiting when death is expected or imminent.

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6. Food, Toiletries and Constitutions

The treatment of food and access to traditional food have different protocols attached to
them. For some cultures, menstruating women should not prepare or serve food due to
their spiritual power. Different protocols can also exist for remains and bodily fluids. For
example, it is important for some cultures to dispose of hair lost through combing in a
particular manner. In many cases, these beliefs will align with good health and safety
procedures that should be practised by the staff and should not need to cause undue
deviation from usual practices.

Staff action:
        Become familiar with the basic principles of your patient‘s nation/culture and
        practical ways of respecting them.

Supported this by:
      The ways in which staff can assist will vary according to the patients and the
      various protocols around the nations/communities the health centre serves. These
      protocols should be determined and developed for staff.

7. Body Parts/Tissues/Substances

This includes the removal, retention or disposal of the placenta and genetic material.

Staff action:
        Follow the correct process for fully communicating with the patient about the
        procedure and consulting them about options for removal, retention, return, or
        disposal. Informed consent must be obtained where required.

In addition, staff should consider the following points where a First Nations, Inuit or
Métis patient is concerned:
        Offering the option of further support from the appropriate Aboriginal staff. This
        should happen before any intervention.
        Returning of body parts/tissue/substance in a way that is consistent with the
        protocols of the patient and in consultation with the appropriate Aboriginal staff.
        For example, body parts/tissues/substances should be returned in containers that
        are durable and reflect First Nations, Inuit and Métis best practices.
        Recording and carrying out the wishes of the Aboriginal patient and/or family if
        the original purpose of retention changes. Returns should follow First Nations,
        Inuit and Métis best practices and protocols determined in consultation with the
        patient, family or Aboriginal staff.
        Returning unconsented body parts/tissues/substances following existing cultural
        protocols of the deceased. If return or retention is not requested, staff should
        discuss and agree to disposal and/or burial of the body parts/tissues/substances
        with the patient and family. This should be carried out in a considered and
        consultative manner that respects accepted First Nations, Inuit and Métis
        community practices.

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Offering the return of a patient‘s hair, fingernails and toenails. These may be
       saved in a patient-labelled plastic bag and returned to the patient or family.
       Documentation in the clinical notes is highly recommended.
       Organ and tissue donation with consent from patient or family.

8. Pending and Following Death

As for any patient, family should be notified, supported and involved where death is
expected. In addition, when a First Nations, Inuit or Métis patient is involved, staff
should immediately notify Aboriginal support staff involved in the care of the patient.

Staff Action:
       Allow for visiting hours outside of those presets by the health centre (if possible).
       Acknowledge that large numbers of family members may be present; work with
       them on how to respect each other‘s needs.
       Be respectful of protocols, show respect for them and allow time for their
       performance.
       Allow the family or traditional person or healer to prepare the body according to
       their customs.
       Work with the family to appoint a contact person, thus minimizing the number of
       calls made—leaders may get involved and act as the point person who is not a
       family member.

Staff actions following death:
        Always consult with the patient‘s family on the protocols for handling the body.
        For example, in some cultures, the body is not left unattended following death.
        Follow the cultural and spiritual protocols of the patient‘s culture at this time.
        Avoid preparing the body until discussed with the family.
        Provide the family opportunity to perform cultural and spiritual rites for the
        deceased.

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Further sources of information on cultural competency and safety
Canadian Council of Health Services Accreditation
Canadian Patient Safety Institute
Ontario Ministry of Health and Long-term Care
Meno-Ya-Win Health Centre (Sioux Lookout)
First Nations Inuit Health Branch, Health Canada (FNIHB)
Nishnawbe-Aski Nation
Indigenous Physicians Association of Canada
Vision 2020 Strategy
NAHO annotated bibliography on Cultural Safety
NAHO Environmental Scan on Health Care Curriculum
U.S. Department of Health and Human Services, Health Resources and Services
Administration.
www.diversityRx.org (Web site resource dedicated to culturally safe health practices)
Aboriginal Nurses Association of Canada
U.S. Department of Health and Human Services, Office of Minority Health.
The Third National Conference on Quality Health Care for Culturally Diverse
Populations: Advancing Effective Health Care through Systems Development, Data, and
Measurement.

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Glossary
Indigenous knowledge: ―Indigenous knowledge is a complete knowledge system with
its own epistemology, philosophy and scientific and logical validity…which can only be
understood by means of pedagogy traditionally employed by the people themselves‖
(Battiste and Henderson, 2000: 41). In other words, Indigenous knowledge is the
collective understanding of how the social, spiritual, political, and economic ways of
understanding the universe and their place within it as a community or nation interacts.
The foundation of these ways of knowing are based on and guided by traditional
interpretations of these ways of understandings in everyday contexts.

Inuit Knowledge or Inuit Qaujimaningit: ―[Inuit Qaujimaningit] (or traditional
knowledge), results from our age-old connection to our land and its living resources, and
the inseparable relationship that exists between our land, resources and culture.
Attachment to the land through personal histories, stories and place names is just as
important as more functional attachments based on areas of good hunting, travel routes
and specific knowledge about the physical environment and living resources.‖ (Accessed
from http://www.itk.ca/environment/tek-understanding.php on April 13, 2007.)

Traditional knowledge: considered synonymous with Indigenous knowledge, but its
common usage generally refers to the history, ceremonies, practices, and beliefs of a
particular group that have been passed down from previous generations.

Family: defined by First Nations, Inuit or Métis can mean persons related by blood, such
as a parent or child, or by adoption. It can also be extended family members such as
aunts, uncles and cousins by both blood and marriage. Family can also include persons
related by clan, kinship lines, shared lands and/or ceremonial or traditional adoptions.

Knowledge transfer: a process in which two different entities share knowledge. This
process is neither hierarchal nor lateral but rather an interaction where information is
shared between individuals or groups in a way that is easily understood by both. It is
sometimes referred to as ―knowledge exchange.‖

Culturally unsafe care/teaching: Can be a situation when values, ethics, knowledge,
and/or epistemologies for First Nation, Inuit and Métis may be different than that of the
health care provider. This is often the result of a negative portrayal of Aboriginal peoples
in curricula; not acknowledging historical experience and effects of colonization on
Aboriginal Peoples; and basic access (geographic, linguistic, cultural) barriers that exist.

Cultural sensitivity: An acknowledgement by the health practitioner/educator that the
patient or student is of a different culture than their own, and therefore may have a
different way of understanding the world. It is possible for a practitioner/ teacher to be
culturally sensitive without necessarily being culturally competent or providing a
culturally safe environment. Sensitivity can be thought of as the first step towards
learning about oneself within the context of one‘s interaction or relationship with people
of a different culture.

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